Just as the CDC's and other experts' thoughts on Ebola and infection control have evolved with experience, mine have taken a slight twist as well. Given the missteps at Dallas’s Texas Presbyterian Hospital, which could have occurred in any community, I now agree with the current recommendations to centralize care in specialty centers. My perspective has changed a bit, particularly given more information about the voluminous diarrhea and vomiting of Ebola victims, and the recent infections of health care workers.

But I feel a sadness, too, that by only having special Ebola SWAT teams trained in response, we are losing a critical and rare opportunity to improve infection control training for all.

— First, they will make sure that health care workers dealing with Ebola patients are "repeatedly trained," especially when it comes to learning how to put on and take off their personal protective equipment.

⁠— Second, the equipment used should leave no skin exposed.

— Third, these regulations should be monitored by a "trained observer" or site manager, who watches each employee take on and off their personal protective equipment

1. Isolate patient in single room with a private bathroom and with the door to hallway closed

2. Implement standard, contact, and droplet precautions

The new CDC recommendations, however, suggest that for any suspected Ebola patient, which could be interpreted as anyone with the appropriate travel history and fever or “symptoms,” an Ebola SWAT team would be called, and that appropriate attire would be the “The Works”—aka the “Full Monty”—with Hazmat suits and N-95 masks or Powered Air Purifying Respirators (PAPRS). The proposed Hazmat PPE makes sense for patients with vomiting and diarrhea and for ICU patients, who presumably have a higher viral load and are more infectious.

As an infectious disease physician in community hospitals, I believe the CDC has made a slight misstep in its new recommendations. I would favor a tiered approach to a response, as follows.

While I understand the need for an Either/Or, all-or-none (go/no-go) decision point in an algorithm, this doesn’t make sense for patients who are not very ill. From a community hospital perspective, this is neither practical nor likely necessary, and will engender more fear and panic, furthering the current epidemic of Ebolanoia. We need to emphasize that most patients in Kikwit and elsewhere have been handled safely without hazmat suits. And even in Dallas, where many people were exposed to Thomas Duncan before he was properly identified as having Ebola and isolated, only the two ICU nurses became infected.

Instead, I would recommend the following tiered approach (details below):

Proposed Risk-based Ebola isolation algorithm

If Ebola might be suspected because of travel or exposure history, initially isolate the patient using standard, contact and droplet precautions.

Flu vs. Ebola

If they have fever and respiratory tract symptoms, as is likely during flu season, use the Personal Protective Equipment (PPE) as per the previous CDC precautions for multi-drug resistant organisms: an impervious gown, gloves, but enhanced with a mask (surgical or N-95) and face shield. Ebola is possible⁠, though less likely. This would be akin to the CDC algorithm’s low-risk exposure.

If the patient presents with GI symptoms sycg as vomiting and diarrhea, the likely infectious risk is higher (whether norovirus or Ebola), so either an impervious gown plus leg coverage or a Tyvek hazmat suit makes better sense. In speaking with several epidemiologists, the Tyvek suits and PAPRs are considerably more comfortable, especially for the nurses who are in contact with the patients for much longer stretches.

If Ebola is confirmed or there was a high-risk exposure and the patient is symptomatic, then it makes sense to have the Ebola SWAT response team activated. It is just too easy for someone inexperienced to contaminate themselves removing PPE, which has been shown previously.

Gowns: For low-medium risk exposures with any isolated patient, especially those I see with multi-drug resistant organisms (MDROs), I prefer the vinyl isolation gowns to the cloth ones, because I can tear these off without possibly contaminating myself while untying strings at the waist or neck. There is no risk of the sleeve sliding up over the glove, leaving skin exposed at the wrist. I also like the vinyl gowns because, when removing gloves, I don’t have to slide my finger under the glove—I can just peel everything off at once. **A video from Emory University shows an excellent way of removing gloves with a "beaked" gloved hand (at 1:30).

I hope this post will help quell some of the growing and unnecessary anxiety regarding Ebola and that we can soon return our focus to the bigger threat—superbugs like the Klebsiella that even kills patients at premiere hospitals.

These Ebola cases should be regarded as a teaching moment and a time to call for necessary changes and a reinvigoration of infection control and epidemiology practices. If the CDC and hospital administrators fail to capitalize upon the impetus for better infection control that we are now seeing with Ebola, that will be a far greater tragedy.

I again call on the CDC and State Health Departments to focus some of their attention away from bioterrorism preparedness and Ebola, to remedial infection control 101. If all health care workers are trained—and retrained, demonstrating proficiency in practice—we can help protect the country from any infectious diseases threat.

The views expressed are those of the author(s) and are not necessarily those of Scientific American.

ABOUT THE AUTHOR(S)

Judy Stone

Judy Stone, MD is an infectious disease specialist, experienced in conducting clinical research. She is the author of Conducting Clinical Research, the essential guide to the topic. She survived 25 years in solo practice in rural Cumberland, Maryland, and is now broadening her horizons. She particularly loves writing about ethical issues, and tilting at windmills in her advocacy for social justice. As part of her overall desire to save the world when she grows up, she has become especially interested in neglected tropical diseases. When not slaving over hot patients, she can be found playing with photography, friends' dogs, or in her garden. Follow on Twitter @drjudystone or on her website.

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Subscribe Now!Why Ebola Is a Wake Up for Infection ControlJust as the CDC’s and other experts’ thoughts on Ebola and infection control have evolved with experience, mine have taken a slight twist as well.

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